National Healthcare Insurance continued...

[MOHS_01]

This is a continuation of the front page topic....

For my .02

The health care model in this country is less than perfect; I believe that most will not argue this point. There are several fundamental principles which need to be addressed if we are to ever hope for meaningful reform. I do not believe that nationalization is the route to correcting our woes, however.

The mission statement for any reform platform should read something like this:

"Our goal is to provide a healthcare system that offers and balances both availability and value."

Access would be encompassed within the availability goal, as would the examination of true workforce needs and deficiencies. Value would cover many areas, but the primary focus should be on quality and affordability (including appropriate cost containment). Medical decision making has to be driven by high quality evidence -- unlike much of medical care today.

Our current system fails miserably in these regards; we have a system that is adversarial and rewards bad medicine.

There is SO much more that I would like to say on this, but I am lacking in time to give the topic its proper due at the moment; hopefully we can keep this thread civil long enough to have a proper discourse.

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[radslooking]

I can certainly agree with you that the system rewards bad medicine. If you want people to do the right thing, you have to incentivize them to do so. By paying for procedure, you are paying for doctors to find more and more ways to do procedures. By allowing doctors to be sued heavily for mistakes you create an atmosphere where they order too many tests "just to be sure". By not enforcing and utilizing evidence based medicine, you allow junk medicine to continue. By not having transparency and interlinking of computer systems, you promote duplication of tests and procedures, mistakes, and poor communication. By allowing direct to consumer advertising you allow patients to pressure doctors into giving them sometimes unnecessary drugs. By not insuring some patients there may be overutilization of expensive emergency care (stolen from my other thread).

Honestly, I rarely get upset when insurance companies medical provider calls me and tells me they aren't going to pay for more hospital days. Most of the time they are correct.

Also, another thing that should happen, honestly, is that there should be a person who reviews medications periodically and assesses whether they should be on them or not. Few people seem to know this--- but antidepressants, protonix, alendronate, etc, are not supposed to be continued indefinitely. As there is NO incentive for the PCP to address stopping these medications, so they are continued forever. Just by having people address this would save millions and result in fewer side effects and generally better health overall.

People should be on the absolute fewest number of medications that keeps them well. Not just the amount of medications that leaves the PCP with the least to think about.

I think we need to take a hard look at end of life care as well, and wonder where we can start to intervene. It's hugely expensive, and hugely ineffective. Hard choices need to be made in this arena.

Stopping or reducing payment for questionable procedures would be nice too. I won't name any here, but they are out there.


Sorry, this is a little long, and not totally related to national health care. More just my personal beliefs with the system as it is. I didn't prioritize what is most important or would change the most about our system. But honestly, I think an honest assessment of our end of life care could provide immediate, large benefits to the bottom line, without affecting, or actually improving QOL. Have a hospital ethics board review cases and say whether surgeries or treatments will be continued for a patient. Take this decision out of family member's hands who don't have medical expertise and are biased in a way that is unhelpful to the process.

Cancer therapies can be questionable as well. Avastin being given at 10's of thousands per month to give a month or two of extra survival is questionable. If you want to pay for that on your own dime, ok. But the gov't shouldn't be shelling that out.

 

[Miami_med]

I think one of the fundamental problems with the argument here though, is that there is no such thing as a true workforce need without a frank discussion as to what services are going to be provided. Everyone has different values that they use to assess what is "needed," elective, and unnecessary. A system that leans heavily on market principles allows individuals to divert their own resources towards their own personal values. Any system that attempts to determine on a grand scale what is needed will likely only work to continue an interest driven system where what is "needed" is determined by what makes the most well connected lobby the most money.

 

[MOHS_01]

I think one of the fundamental problems with the argument here though, is that there is no such thing as a true workforce need without a frank discussion as to what services are going to be provided. Everyone has different values that they use to assess what is "needed," elective, and unnecessary. A system that leans heavily on market principles allows individuals to divert their own resources toward their own personal values. Any system that attempts to determine on a grand scale what is needed will likely only work to continue an interest driven system where what is "needed" is determined by what makes the most well connected lobby the most money.

That is precisely my point -- the physician "workforce" deficiencies, as currently perceived, are largely a product of the flawed system that we have in place today. You have physicians who want more spots in radiology, dermatology, plastic surgery, etc. You have patients (and payers) who want more providers period so that they can be seen on the same day, for less money, at their whim. On and on... there is an angle for every interest involved.

You also make another point that I have touched upon many times in the past -- the need for frank discussions on the matter, not cloaked in pointless idyllic niceties with little root in reality. The fact of the matter is that we spend an inordinate sum of money for less than ideal outcomes. Some of this has little to do with our healthcare system per se and more to do with our societal ills.

Providers are not happy, patients are not happy, no one other than insurance execs seem to be winning in the current setup. All too often as providers we don't know which interventions work (the best), are the most cost effective, etc. Fear of litigation drives some needless testing and care, but an adequate quantification of this I have yet to see.

While I tend to be a believer of the invisible hand of the market, I don't hold out much hope for any widespread free market application in the healthcare arena during my lifetime. We are simply too entrenched in the entitlement "right" of healthcare, both public and private. Free market principles cannot work if the bar for everyone in the playing field is set by a federal entitlement program (who happens to be in bed with the largest provider organization).

Lastly, there will always be "interests". You cannot have a competitive enterprise system without them.

 

[Miami_med]

Interests are great. Money interests function well in a market system, because you can only make money by providing a good or service that people are willing to buy with their own resources in a such a system. In a socialized system, money interests suddenly become destructive because they pull resources out of a limited collective pie.

 

[radslooking]

Fear of litigation drives some needless testing and care, but an adequate quantification of this I have yet to see.

As to this specific point, i agree with you that it is probably too simplistic. Fear of litigation is only one part of it. Even with no fear of litigation, i am still pretty sure we would overtest a lot of things, just because that's the American culture---we rely little on physical exam/history taking/clinical acumen, and rely very heavy on technology for our diagnoses. Moreover, our culture is one of not waiting and watching...its of actively doing something until you have an answer. Oftentimes, on the wards, I brought up as few complaints as i possibly could...because if it came out of my mouth, something had to be done about it. And waiting was rarely an acceptable answer...even though it should have been. We for too long have been a country that needs an answer or a treatment...at all costs. And that mentality simply can't continue. The consequences are already being seen. We can't fund Medicare, and our employer sponsored healthcare companies, like GM and Ford--simply can't compete. There are consequences to this behavior.